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Based on document review, video surveillance, and interview it was determined that the Hospital failed to protect and promote patients' rights by failing to activate a response team and follow de-escalation techniques for a patient with escalating agitated behaviors. This places patients with escalating agitated behaviors at risk for harm, serious injury or death. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights was not in compliance.

Findings include:

1. The Hospital failed to ensure care in a safe setting by failing to ensure an appropriate response team was activated and de-escalation techniques were followed for a patient with escalating agitated behaviors. See A-144.

The immediate jeopardy (IJ) began on 02/09/2023 due to the Hospital's failure to appropriately activate a response team to intervene and ensure the use of de-escalation techniques for a patient, with escalated agitated behaviors while on the Geropsychiatric unit. As a result, the patient had an altercation with staff and sustained an injury to the left thumb. Subsequently patient was transferred to higher level of care for further management. The IJ was identified on 04/13/2023 at 42 CFR 482.13, Patient Rights, and was announced the same day at 12:15 PM, during a meeting with Chief Nurse Officer, Chief Executive Officer, and Quality Assessment Coordinator. The IJ was not removed by the survey exit date of 04/17/2023.

Based on document review, video surveillance, and interview, it was determined that for 1 of 3 patients (Pt. #1) clinical records reviewed regarding allegations of abuse, the Hospital failed to ensure care in a safe setting by failing to ensure an appropriate response team was activated and de-escalation techniques were followed for a patient with escalating agitated behaviors.

Findings include:

1. On 04/10/2023 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to 5 B Geropsychiatric Unit on 02/06/2023 with a diagnosis of schizoaffective disorder. The clinical record indicated that on 02/09/2023 at 7:00 PM, Pt. #1 was agitated, verbally abusive, and was threatening the hospital staff. Pt. #1's clinical record included the following:

-The Mental Health Counselor (MHC) note dated 02/06/2023 at 9:44 PM, included, "Patient [Pt. #1] present in the milieu with noted anxiety and restlessness. When redirected the patient tends to resist, frown, and make a sarcastic remark ...irritable, sarcastic, and resist redirections..."

-The MHC (E #1) note dated 02/08/2023 at 9:38 PM included, "Patient [Pt. #1] was involved in a verbal altercation with his male peer ...exchange of profanity of threats were made by each party ...writer intervened and separated ...they would keep distance."

-The House Physician note dated 02/09/2023 at 7:45 PM, included, "Pt. [Pt. #1] brought to ED bc [because] ... bit tip of Lt. [left] thumb ...has distal part with him -placed in NS [normal saline] Distal part included nail, nail bed, and small amt. [amount] of tissue ...tip of thumb was macerated tissue with mim [minimal] bleeding, bone visible ...unable to oversew bc wound gapes ...CT [computerized tomography] ordered ...has small abrasion to Lt. [left] ear -bleeding stopped ...will transfer to [Name of Sister Hospital] ..."

2. On 04/13/2023, the Hospital's "Incident Report" dated 02/09/2023 at 7:00 PM indicated that an altercation occurred between E. #1 (MHC) and Pt.#1. E #1 was choked, punched, and hit by Pt. #1. E #1 bit Pt. #1's left thumb and nail was removed.

3. On 04/13/2023, the Hospital's "Follow up/Investigation Report" dated 02/10/23 indicated that Pt. #1 became verbally abusive with E #7 (MHC), after attempting to redirect the patient. Pt. #1's behaviors escalated, and the nurse (E #2) requested for security and other staff to assist to provide medication. Pt. #1 had E #1 on a headlock and was laying on top of E #1. The other staff in the room tried to remove Pt. #1 off E #1 but were not successful. E #1 injured Pt. #1 by biting Pt. #'1's left thumb.

4. On 04/13/2023, the Hospital's policy titled "Management of Patient Agitation" dated 03/2022, was reviewed and included, "Removes the source of the stimulation causing the agitation or removes the agitated patient from the stimulus..."

5. On 04/13/2023, the Hospital's policy titled, "Code Gray" dated 02/1994, was reviewed and included, "All Security staff on the property is to respond regardless of being on duty or off duty. All adult mental health staff available is to respond as well ...Security staff responsibility is to assist staff..."

6. On 04/11/2023, at approximately 10:30 AM, the video surveillance dated 02/09/2023 related to Pt. #1's incident was reviewed. The camera view was of the Geropsychiatric Unit 5B W Hall Entrance and 5 B E Hallway. The following was observed:

-At 7:28 PM: Pt. #1 is observed at the Nurses' station moving his head left and right, moving arms up and down, would point at E #7 (MHC), and continue to move arms up down. Pt. #1 would get close to E #7 and lean over E #7 and point finger at E #7. At one point Pt. #1 pushed E #7. E #1 puts arm between Pt. #1 and E #7 (no physical contact). E #8 (Security Officer) escorts Pt. #1 to the assigned room and Pt. #1 enters the room. E #8 remains at the doorway. E #1, E #7, E #2 (Registered Nurse) and E #8 are seen at Pt. #1's room doorway. E #8 enters Pt. #1's room, followed by E #2. Then E #1 and E #7 enter the room at the same time. Shortly after E #2 is seen running out of Pt. #1's room and goes to the Nurses's station and is seen on the phone.
-At 7:33 PM E #1 exits Pt. #1's room.
-At 7:42 PM, E #9 (MHC) enters the unit to assist in Pt. #1's care and takes Pt. #1 to the emergency department for evaluation.

7. On 04/12/2023 at 11:10 AM, the MHC (E #1) was interviewed. E #1 stated Pt. #1 was agitated and fixated toward E #7 and E #1. E #1 also stated that based on CPI training another staff should have been assigned to address and de-escalate the patient. E #1 also stated there was no plan by the team when they entered Pt. #1's room.

8. On 04/12/2023 at 11:51 AM, the Registered Nurse (E #2) was interviewed. E #2 stated that she did not call for a code gray (security and all available staff assistance needed) and just called the security officer to assist with the situation (Pt. #1's escalated behavior). E #2 stated that she was not aware that Pt. #1 had an altercation with E #1 the night before. E #2 stated there was no plan made with the team prior to entering Pt. #1's room to administer the medication.

9. On 04/12/2023 at 1:00 PM, the Chief Nursing Officer (E #6) was interviewed. E #6 agreed that the nurse could have called for a code gray and if the third MHC (E #9) had come to assist earlier the situation could have been avoided. E #6 stated that the patient (Pt. #1) was fixated on the MHC (E #7) that was on the unit, and the MHC (E #1) who had an altercation with the patient (Pt. #1) the night before. E #6 stated both the MHC's (E #1 and E #7) were not the right choice for assisting with the situation. E #6 stated, "We did not do a root cause analysis of this incident." E #6 stated that other than have E #1 on a 45-day performance evaluation and in- serviced on patient rights no additional interventions or education has been implemented after the incident with Pt. #1.

Based on document review and interview, it was determined that for 1 of 4 patients (Pt. #1), clinical records reviewed for restraints, the Hospital failed to ensure a physician's order for restraints was obtained, as required, while patient was on physical hold during agitation.

Findings include:

1. The Hospital's policy titled "Restraints", dated 06/2021, was reviewed and included, " ...Physical Hold: The use of a physical hold on the patient in a manner that restricts the patient's movement against their will to administer a medication or performing a task or procedure against the patient's wishes is considered a restraint and all the requirements would apply ... The use of force in order to medicate a patient, must have a physician's order prior to the application of restraint ... if physician order was unable to be obtained prior to the application of physical hold, the order must be obtained immediately within a few minutes after application of the physical hold ..."

2. On 04/13/2023, the Hospital's "Follow up/Investigation Report" dated 02/10/23 indicated that Pt. #1 became verbally abusive with E #7 (MHC), after attempting to redirect the patient. Pt. #1's behaviors escalated, and the nurse (E #2) requested for security and other staff to assist to provide medication. Pt. #1 had E #1 on a headlock and was laying on top of E #1. The other staff in the room tried to remove Pt. #1 off E #1 but were not successful. E #1 injured Pt. #1 by biting Pt. #'1's left thumb.

3. On 04/10/2023 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to 5B Geropsychiatric Unit on 02/06/2023 with a diagnosis of schizoaffective disorder. The clinical record indicated that on 02/09/2023 at 7:30 PM, Pt. #1 was agitated, verbally abusive, and was threatening the hospital staff. The clinical record did not include a physician's order for restraints.

4. On 04/12/2023 at approximately 1:52 PM, an interview was conducted with the E #2 (Registered Nurse). E #2 stated that security was called to the unit due to Pt. #1's escalating agitated behaviors and required assistance to administer medication. E #2 stated there was no plan made with the team prior to entering Pt. #1's room. In the patient's room security officer (E #8) and E #7 (MHC) was trying to hold the patient (Pt. #1) during agitation. E #2 stated that the hold was released after the administration of medication. E #2 stated that a physician's order for restraints wasn't obtained for the restraint (physical hold).

5. On 04/12/2023 at approximately 2:30 PM, the findings were discussed with the Nurse Manager/Nursing Supervisor (E #5). E #5 stated that physical hold is considered as a restraint. E #5 stated that the nurse should have obtained the physician's order for restraints after the event.